South of the Border

Friday, March 2nd, 2018

The Pelvic Floor Revolution

Though orthopedics has always been my passion, a few years ago I decided to dive into the fascinating world of pelvic floor physical therapy. While I found learning about the anatomy, pathology, treatment and all that sciencey-stuff to be great, what absolutely floored me (pun absolutely intended) was the complete lack of visibility and general awareness of all things related to the pelvic floor. Thus, I decided to drag out my trusty soap-box in an effort to begin what I imagine will one day be known as “The Pelvic Floor Revolution”…or something like that. So please, read and learn, and email me with any questions you may have. Also, check out The Pelvic Guru on Facebook and prepare to have your mind blown. 

What is the pelvic floor?

The pelvic floor refers to the muscles, ligaments, and connective tissue that sits at the bottom of your pelvis, spanning the area from your pubic bone to your sacrum and coccyx. I won't bore you with all the polysyllabic anatomical names for the muscle that make up the pelvic floor, just suffice to say there is more than one muscle and they are all very important. For a more in-depth anatomy lesson, click here.

Who has a pelvic floor?

Everyone has a pelvic floor. I repeat, EVERYONE has a pelvic floor. Men, women, children, adults…everyone.

What does the pelvic floor do?

The pelvic floor serves as a supportive sling, providing a base for the organs of the abdominal cavity, specifically the bladder, urethra, rectum, bowel, ueterus (women), and prostate (men). Healthy pelvic floor function is imperative for voiding, maintaining continence, GI functioning, sexual function, breathing, core activity and basically anything and everything in life.

When I explain the role of the pelvic floor to my patients I like to have them think of a canister, with the top being the diaphragm, the front being your “abs” and transverse abdominis, the sides being your obliques and transverse abdominis, the back being your back muscles, and the bottom being your pelvic floor. When viewed this way, the absolutely integral role that the pelvic floor plays in healthy abdominal and thoracic function becomes immediately apparent. 

What exactly is pelvic floor dysfunction and what can it cause?

Pelvic floor dysfunction can present in a number of ways, loosely categorized into tightness, weakness, poor coordination, and/or pain, with the possibility of all four being present. The consequences of pelvic floor dysfunction are varied. At my clinic I see and treat a wide variety of pelvic floor pathologies, with the most common being: 

Pelvic pain – Pain in the lowest part of your abdomen and pelvis. Some examples include urethral pain, perineal pain, rectal pain, vaginal pain, penile pain, testicular pain. Yes folks, I said vaginal, penile, and testicular. Get used to it. Be ok with it. Time to put on your big kid pants and get comfortable talking basic about human anatomy. Depending on the source of the pain, symptoms may be dull or sharp, constant or intermittent, mild to severe, and can radiate down the legs or up the abdomen and back.

Vulvadynia – Chronic vulvar (the external genital organs of the female) pain without an identifiable cause. The location, constancy and severity of the pain varies among sufferers. It is described by most patients a burning, stinging, irritation, or rawness.

Vaginismus – An involuntary spasming of the muscles of the vagina causing discomfort, pain, and difficulty with or the complete inability to tolerate penetration.

Dyspareunia – Painful intercourse.

Urinary/fecal incontinence – The loss of bladder/bowel control. Leaking when you do those box jumps or double-unders? Time to speak with a pelvic floor physical therapist.

Urinary urge – A sudden and unstoppable need need to urinate, even though the bladder may contain only a small amount of urine. 

Urinary frequency – The need to urinate more than usual (yes, that is the official definition).

Pelvic organ prolapse – A falling or sliding out of place of the one or more of the pelvic organs –  the bladder, uterus, urethra, and rectum – into the vaginal area.

Constipation – Pretty self-explanatory but for those of you who like things spelled out: difficulty emptying the bowels, usually associated with hardened feces. 

GI dysfunction – Including but not limited to irregular bowel movements, pain/bloating after eating, gassiness, nausea, decreased appetite.   

How does pregnancy affect the pelvic floor?

Pregnancy places a TON of stress on the pelvic floor. Remember all those organs I told you the pelvic floor had to support, now add to that the weight of a growing fetus and multiply by 40 weeks. Constipation is also common in pregnant women, which places additional stress on the pelvic floor. All this stress and stretching, and this is BEFORE the baby is even born. During childbirth, the muscles of the pelvic floor are stretched and can be torn. A stretched, weakened, and injured pelvic floor can lead to urinary and/or fecal incontinence along with pelvic organ prolapse (see above for definition).

Why should men care about the pelvic floor?

Well, for starters, because they have one and should care about the functioning of their body. More specifically, though men obviously cannot present with vulvadynia, they can experience pelvic floor dysfunction that causes as penile, testicular, perineal, or rectal pain. I've treated numerous men who have been told for months on end that they had bacterial prostatitis and been treated unsuccessfully with antibiotics, only for us to discover the the actual problem was pelvic floor dysfunction. Men, like women, can experience pelvic floor dysfunction that interferes with urination, bowel function, and sexual function. For some people, this pelvic pain becomes so severe that they are unable to sit or wear tight-fitting clothing. And don't even think about asking them to ride a bike! Though we tend to associate conversations about the pelvic floor with the hushed-whispers of post-partum mothers leaking their way through their Zumba classes, pelvic floor dysfunction is something that can and does affect both men and women of all ages. 

What causes pelvic floor dysfunction?

The cause of pelvic floor dysfunction is often multifactorial, and sometimes, I'm not going to lie, unknown. As a pelvic floor PT, and as a PT in general, I always look to find and treat the cause of the dysfunction, but sometimes all we can do is start with symptom management and work from there. Some major players in the cause of pelvic floor dysfunction and pain include:

  • Childbirth
  • Chronic tensing – often seen in (but not at all limited to) dancers, gymnasts, and those with poor pelvic floor awareness
  • Stress/anxiety
  • Hip dysfunction/pathology – example: labral tears
  • Diet
  • Neurological involvement
  • Constipation – yes this can cause or be caused by pelvic floor dysfunction

How is pelvic floor dysfunction treated?

While pelvic floor physical therapy isn't necessarily the pelvic floor dysfunction panacea, it is a great start. A trained pelvic floor therapist is able to evaluate your pelvic floor via an internal exam and assess muscle function directly. Additionally, pelvic floor physical therapists understand the relationship between the pelvic floor and the rest of the body, therefore making them well-suited to identify how dysfunction at a different part of the body could affect or cause pelvic floor dysfunction and vice-versa. Once being examined by a trained therapist, a treatment plan is established based on the cause of the dysfunction. Manual techniques (internal or external massage), breathing exercises, postural corrections, relaxation techniques, visceral mobilization (fancy abdominal massage), biofeedback, and electrical stimulation are just a few tools in the pelvic floor PT toolbox. Regarding exercises, there is more to pelvic floor rehab than just kegels! As explained early, the pelvic floor interacts directly with the hips, core, and back, and thus assessing and involving these structures is paramount. For more information on pelvic floor therapy email me here or click here for links to some must-read resources.

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